Primary care as public utility: Imagine that, researchers urge

A team of healthcare scholars is making U.S. states an offer they hope the border-defined polities won’t refuse: If you’ll pay for the reinvention of primary care—a sorely needed project—we’ll help sell the public on the rightness of measured, state-level efforts to preserve the profession.

That’s a paraphrase. Here are their exact words: 

‘Many states are working to bolster primary care, but they face common challenges related to federalism, fragmentation of health insurance and administrative hurdles that undermine their efforts to invest in primary care. … To overcome these challenges, we propose that states invest in primary care as a public utility. We propose a financing model for primary care that is unified and streamlined across payers, in keeping with primary care as a common good, through a common fund.’

Led by Zirui Song, MD, PhD, of Harvard Medical School, the group makes its case in the Journal of the American Medical Association.

Why fix something that isn’t broken per se? Because more than one-third of U.S. adults lack access to primary care, Song and colleagues point out, adding that the specialty has “increasingly become a commodity rather than the common good envisioned by the National Academies of Sciences, Engineering and Medicine.”

The proposal describes six linchpins that, together, would enable primary care to function like a de facto public utility. Excerpts from that section:

1. The common fund—analogous to other state funds for essential services (eg, food, housing, education)—would comprise current primary care spending from payers and in the future include additional spending that states invest into primary care. “A state authority, analogous to a public utility, would administer this common fund and pay practices, limited only by federal preemption of benefits for residents enrolled in federal programs,” Song and co-researchers write. 

2. The underlying pluralistic financing of primary care would remain intact. “Employers and individuals would continue to pay premiums for commercial plans, and Medicaid would continue to be financed by federal and state funds. However, on the back end, the state would redirect the primary care portion of insurer premiums (their contribution) to this common fund responsible for paying primary care practices.”

3. Contributions to the common fund would initially be based on what these entities are already spending on primary care. “For example, a state like Oregon, which has a primary care spending target of 12%, would assess 12% of plan premiums. Future contributions would be indexed to a state’s plan to incrementally raise its share of spending on primary care.”

4. A key point is that the common fund starts with no “new money.” “Baseline contributions equal what insurers and purchasers are already spending on primary care. Payers would still compete on their specialty and other lines of business, but they would no longer need to compete on prices and benefits for primary care; rather, they would coinvest in primary care as a mutual asset.”

5. New money would be required for a state to include individuals without insurance in the primary care public utility. “Treating primary care as a common good justifies including individuals without insurance, especially as people lose coverage due to federal action on Medicaid and state ACA exchanges. Still, new money for those without insurance is not entirely new because uncompensated care is ultimately paid for by taxpayers.”

6. People would remain enrolled in insurance for non–primary care services. However, the common fund “would assume responsibility for coverage and payment of primary care and accountability for its spending. By pooling revenues, the common fund would function as a multipayer-financed but state-administered primary care resource pool. It would price primary care services or determine per member per month payments.” 

Song and colleagues flesh out these points and more particulars in their vision for primary care as a public utility. JAMA subscribers can read the rest of the proposal here.